乳房 X 光攝影影像判讀的標準化報告系統
目的：為了避免錯誤解讀乳房攝影的檢查結果，使用標準化的報告格式、詞彙、
分類與建議處置，可讓臨床醫師充分瞭解報告內容與含意，做出適當的決策。此
外影像檢查不具專一性，良性與惡性腫瘤可出現相似的表徵，為了提高診斷率並
減少偽陽性對篩檢婦女的傷害，標準化報告系統可作為判讀醫師執行醫學評量的
基礎。
方法：
一、乳房 X 光攝影標準化報告格式。
1. 基本資料: 姓名、病歷號、年齡或出生年月日、檢查日期
2. 檢查名稱: 兩側或單側檢查、篩檢或診斷式乳房 X 光攝影
3. 報告內容: 是否比較舊片，乳腺緻密度分類(詳見二.)，異常發現(有)(無)，
建議使用統一的詞彙 (詳見三.)
4. 分類與建議處置: (詳見四.)
5. 判讀醫師: 姓名、專科醫師證書字號
二、乳腺緻密度(BREAST COMPOSITION)
1. The breast is almost entirely fat (<25% glandular).
2. There are scattered fibroglandular densities (approximately 25%-50%
glandular).
3. The breast tissue is heterogeneously dense, which could obscure detection of
small masses (approximately 51%-75% glandular).
4. The breast tissue is extremely dense. This may lower the sensitivity of
mammography (>75% glandular).
三、報告內容所使用的統一詞彙。
A. MASSES
A “MASS” is a space-occupying lesion seen in two different projections. If a
potential mass is seen in only a single projection it should be called an
“ASYMMETRY” until its three-dimensionality is confirmed.
1. SHAPE
a. Round
A mass that is spherical, ball-shaped, circular or globular in shape.
b. Oval
A mass that is elliptical or egg-shaped.
c. Lobular
A mass that has an undulating contour.
d. Irregular
The lesion’s shape cannot be characterized by any of the above.
2. MARGIN ( Modifies the shape of the mass )
a. Circumscribed (Well-Defined or Sharply-Defined) Margin
The margin is sharply demarcated (at least 75% of the margin must be
well defined, with the remainder no worse than obscured by overlying
tissue, for a mass to qualify as “circumscribed“) with an abrupt
transition between the lesion and the surrounding tissue. Without
additional modifiers there is nothing to suggest infiltration. A mass,
where any portion of the border is indistinct or spiculated should be
classified on the basis of the latter.
b. Microlobulated
The short cycles of the margin produces small undulations.
c. Obscured
A margin that is hidden by superimposed or adjacent normal tissue.
This is used when interpreting physician believes that the mass is
circumscribed, but the margin is hidden.
d. Indistinct (Ill-Defined) Margin
The poor definition of the margin or any portion of the margin raises
concern that there may be infiltration by the lesion and this
appearance is not likely due to superimposed normal breast tissue.
e. Spiculated Margin
The lesion is characterized by lines radiating from the margin of a
mass.
3. Density
This is used to define the x-ray attenuation of the lesion relative to the
expected attenuation of an equal volume of fiborglandular breast tissue.
It is important that most breast cancers that form a visible mass are of
equal or higher density than an equal volume of fibroglandular breast
tissue. It is rare (although not impossible) for breast cancer to be lower
in density. Breast cancers are never fat-containing (radiolucent)
although they may trap fat.
a. High-Density
b. Equal Density (Isodense)
c. Low Density, but not fat-containing
d. Fat-Containing Radiolucent
This includes all lesions containing fat such as an oil cyst, lipoma or
galactocele as well as mixed lesions such as the hamartoma or
fiboradenolipoma. Since specificity is lower than sensitivity, it is
important to stress the benign nature of mammographic features when
possible. A fat-containing mass will overwhelmingly represent a
benign mass.
B. CALCIFICATIONS
Calcifications that can be identified as benign on mammography are typically
larger, coarser, round with smooth margins and more easily seen than
malignant calcifications. Calcifications associated with malignancy (and
many benign calcifications as well) are usually very small and often require
the use of a magnifying glass to be seen well.
When a specific etiology cannot be given, a description of calcifications
should include their morphology and distribution. Calcifications that are
obviously benign need not always be reported. However, they should be
reported if the interpreting physician is concerned that other observers might
misinterpret them. When vascular calcifications are noted, especially in
women under 50 years of age there are data to suggest potential risk of
coronary artery disease (2-3).
1. Typically benign
a. Skin Calcifications
These are usually lucent-centered and often pathognomonic in their
appearance. Skin calcifications are most commonly seen along the
inframammary fold parasternally, axilla and areola. Unusual forms
may be confirmed as skin deposits by performing mammographic
views tangential to the overlying skin.
b. Vascular Calcifications
Parallel tracks, or linear calcifications that are clearly associated with
tubular structures.
c. Coarse or “Popcorn-like” Calcifications
These are the classic large (>2-3 mm in diameter) calcifications
produced by an involuting fibroadenoma.
d. Large Rod-like Calcifications
These benign calcifications associated with ductal ectasia may form
solid or discontinuous smooth linear rods, usually ≥ 1 mm in diameter.
They can have lucent centers if the calcium is in the wall of the duct
and will generally be solid when secretions calcify in the lumen of
ecstatic ducts. These follow a ductal distribution, radiating toward the
nipple, and occasionally branching, and they are usually bilateral.
Secretory calcifications are usually seen in women older than 60
years.
e. Round Calcifications
When multiple, they may vary in size. They can be considered benign
when scattered. When small (< 1 mm), they frequently are formed in
the acini of lobules. When smaller than 0.5 mm, the term “punctate”
can be used. An isolated cluster of punctate calcifications may warrant
close surveillance or even biopsy if new or ipsilateral to a cancer,
though further study is warranted.
f. Lucent-Centered Calcifications
These are benign calcifications that a centimeter or more. These
deposits are round or oval, with smooth surfaces and have a lucent
center. The “wall” that is created is thicker than the “rim” or “eggshell”
type of calcifications. lncluded are areas of fat necrosis and calcified
debris in ducts.
g. “Eggshell” or “Rim” Calcifications
These are very thin benign calcifications that appear as calcium
deposited on the surface of a sphere. These deposits are usually smaller
than 1 mm in thickness when viewed on edge. Fat necrosis and
calcifications in the wall of cysts are the most common “rim”
calcifications.
h. Milk of Calcium Calcifications
This is a manifestation of sedimented calcifications in macro or
microcysts. On the craniocaudal image they are often less evident and
appear as fuzzy, round, amorphous deposits, while on the 90° lateral,
they are more clearly defined, semilunar, crescent shaped, curvilinear
(concave up) or linear defining the dependent portion of cysts. The
most important feature of these calcifications is the apparent change in
shape of the calcific particles on different mammographic projections
(craniocaudal versus oblique or 90° lateral).
i. Suture Calcifications
These represent calcium deposited on suture material. They are
typically linear or tubular in appearance and when present, knots are
frequently visible.
j. Dystrophic Calcifications
These usually form in then irradiated breast or in the breast following
trauma. Although irregular in shape, they are coarse and usually larger
than 0.5 mm in size. They often have lucent centers.
2. Intermediate concern, suspicious calcifications
a. Amorphous or Indistinct Calcifications
These are sufficiently small or hazy in appearance that a more
specific morphologic classification cannot be determined, Diffuse
scattered amorphous calcifications can usually be dismissed as benign
although baseline magnification views may be helpful. Amorphous
calcifications in a clustered, regional, linear or segmental distribution
may warrant biopsy.
b. Coarse Heterogeneous Calcifications
These are irregular, conspicuous calcifications that are generally
larger than 0.5mm and tend to coalesce but are not the size of
irregular dystrophic calcifications. They may be associated with
malignancy but can be present in areas of fibrosis, fibroadenomas or
trauma representing evolving dystrophic calcifications.
3. Higher probability malignancy
a. Fine Pleomorphic Calcifications
These are usually more conspicuous than the amorphic forms and are
neither typically benign nor typically malignant irregular
calcifications. They vary in sizes and shapes that are usually smaller
than 0.5 mm in diameter.
b. Fine Linear of Fine-Linear Branching Calcifications
These are thin, linear or curvilinear irregular calcifications, which
may be discontinuous and smaller than 0.5 mm in width. Their
appearance suggests filling of the lumen of a duct involved irregularly
by breast cancer.
4. Distribution modifiers
These are used to describe the arrangement of calcifications in the breast.
Multiple similar groups may be indicated in the report when there is
more than one group of calcifications that are similar in morphology and
distribution.
a. Diffuse / Scattered
These are calcifications that are distributed randomly throughout the
breast. Punctate and amorphous calcifications in this distribution are
usually benign and usually bilateral.
b. Regional
These are calcifications scattered in a large volume (> 2 cc) of breast
tissue not conforming to a duct distribution. Since this distribution
may involve most of a quadrant or more than a single quadrant,
malignancy is less likely. However, evaluation must include element
shape as well as distribution.
c. Grouped or Clustered
Should be used when at least five calcifications occupy a small
volume (< 1 cc) of tissue.
d. Linear
Calcifications arrayed in a line. This distribution may elevate
suspicion for malignancy as it suggests deposits in a duct.
e. Segmental
Calcifications in a segmental distribution are worrisome in that they
suggest deposits in a duct or ducts and their branches raise the
possibility of extensive or multifocal breast cancer in a lobe or
segmental calcifications exist (e.g., secretory calcifications), the
smooth, rod-like morphology and large size of individual
calcifications can help distinguish benign calcification from finer,
more irregular malignant calcifications. A segmental distribution may
elevate suspicion for calcifications such as round (punctuate) or
amorphous forms.
C. ARCHITECTURAL DISTORTION
The normal architecture is distorted with no definite mass visible. This
includes thin lines or spiculations radiating from a point and focal retraction
or distortion of the edge of the parenchyma. Architectural distortion can also
be associated with a mass, asymmetry or calcifications. In the absence of
appropriate history of trauma or surgery, architectural distortion is suspicious
for malignancy or radial scar and biopsy is appropriate.
D. SPECIAL CASES
1. Asymmetric tubular structure / solitary dilated duct
This is a tubular or branching structure that that likely represents a dilated
or otherwise enlarged duct. If unassociated with other suspicious clinical
or mammographic findings, it is usually of minor significance.
2. Intramammary lymph node
Intramammary lymph nodes are typically reniform or have a radiolucent
notch due to fat at the hilum and are generally 1 cm or smaller in size.
They may be larger than 1 cm and identified as normal when fat
replacement is pronounced. They may be multiple, or marked fat
replacement may cause a single lymph node to look like several rounded
masses. This specific diagnosis is reserved for masses, usually in the
lateral and upper portions of the breast, although they may occur anywhere
in the breast.
3. Global asymmetry
Asymmetric breast tissue is judged relative to the corresponding area in
the contralateral breast and represents a greater volume of breast tissue
over a significant portion of the breast. There is no mass, distorted
architecture or associated suspicious calcifications. Global asymmetric
breast tissue usually represents a normal variation, but may be significant
when it corresponds to a palpable abnormality.
4. Focal asymmetry
This is a finding that does not fit criteria of a mass. It is visible as a
confined asymmetry with a similar shape on two views, but completely
lacking borders and the conspicuity of a true mass. It could represent an
island of normal breast tissue, particularly when there is interspersed fat,
but its lack of specific benign characteristics may warrant further
evaluation.
E.
ASSOCIATED FINDINGS
Used with masses. Asymmetries, or calcifications or may stand alone as
FINDINGS when no other abnormality is present.
1. Skin retraction
The skin is pulled in abnormally.
2. Nipple retraction
The nipple is pulled in or inverted. This is often bilateral and when stable
and chronic in the absence of any other suspicious findings is not a sign
of malignancy.
3. Skin thickening
This may be focal or diffuse and larger than 2 mm.
4. Trabecular thickening
This is a thickening of the fibrous septa of the breast.
5. Skin lesion
Commented on when it projects over the breast in two views and may be
mistaken for an intramammary lesion. These should be marked by the
technologist with a radiopaque marker and recorded on patient
worksheet.
6. Axillary adenopathy
Enlarged (>2cm), non-fatty replaced axillary lymph nodes mat warrant
comment, clinical correlation and additional evaluation if new.
7. Architectural distortion
As an ASSOCIATED FINDING it can be used in conjunction with a
finding to indicate that the normal tissue structure is distorted or retracted
adjacent to the FINDINGS.
8. Calcifications
As an ASSOCIATED FINDING, it can be used in conjunction with a
FINDING to describe calcifications within or immediately adjacent to the
finding.
F. 描述病灶位置(location)：如：外上象限(upper outer quadrant or UOQ)；內
上象限(upper inner quadrant or UIQ)；外下象限(lower outer quadrant or
LOQ)；內下象限(lower inner quadrant or LIQ)，亦可使用鐘面描述病灶位
置如：三點鐘方向距離乳頭三公分。
四、分類與建議處置 Assessment Categories
a. Mammography Assessment Is Complete
Category 0
Need Additional Imaging Evaluation and/or Prior Mammograms For
Comparison：
Finding for which additional imaging evaluation is needed. This is almost
always used in a screening situation. Under certain circumstances this
category may be used after a full mammographic work-up. A
recommendation for additional imaging evaluation may include, but is not
limited to the use of spot compression, magnification, special mammographic
views and ultrasound.
Whenever possible, if the study is not negative and does not contain a
typically benign finding, the current examination should be compared to
previous studies. The radiologist should use judgment on how vigorously to
attempt obtaining previous studies. Category 0 should only be used for old
film comparison when such comparison is required to make a final
assessment.
b. Mammographic Assessment Is Complete-Final Categories
Category 1
Negative：
There is nothing to comment on. The breasts are symmetric and no masses,
architectural distortion or suspicious calcifications are present.
Category 2
Benign Finding(s)：
Like Category 1, this is a “normal” assessment, but here, the interpreter
chooses to describe a benign finding in the mammography report. Involuting,
calcified fibroadenomas, multiple secretory calcifications, fat-containing
lesions such as oil cysts, lipomas, galactoceles and mixed-density
hamartomas all have characteristically benign appearances, and may be
labeled with confidence. The interpreter may also choose to describe
intramammary lymph nodes, vascular calcifications, implants or architectural
distortion clearly related to prior surgery while still concluding that there is
no mammographic evidence of malignancy.
Note that both Category 1 and Category 2 assessments indicate that there is
no mammographic evidence of malignancy. The difference is that Category 2
should be used when describing one or more specific benign mammographic
findings in the report, whereas Category 1 should be used when no such
findings are described.
Category 3
Probably Benign Finding-Initial Short-Interval Follow-Up Suggested：
A finding placed in this category should have less than a 2% risk of
malignancy. It is not expected to change over the follow-up interval, but the
radiologist would prefer to establish its stability.
There are several prospective clinical studies demonstrating the safety and
efficacy of initial short-term follow-up for specific mammographic findings.
Three specific findings are described as being probably benign (the
noncalcified circumscribed solid mass, the focal asymmetry and the cluster
of round﹝punctate﹞calcifications; the latter is anecdotally considered by
some radiologists to be an absolutely benign feature). All the published
studies emphasize the need to conduct a complete diagnostic imaging
evaluation before making a probably benign (Category 3) assessment; hence
it is inadvisable to render such an assessment when interpreting a screening
examination. Also, all the published studies exclude palpable lesions, so the
use of a probably benign assessment for a palpable lesion is not supported by
scientific data. Finally, evidence from all the published studies indicate the
need for probably benign findings increase in size or extent.
While the vast majority of findings in this category will be managed with an
initial short-term follow-up (6 months) examination followed by additional
examinations until longer-term (2 years or longer) stability is demonstrated,
there may be occasions where biopsy is done (patient wishes or clinical
concerns).
Category 4
Suspicious Abnormality-Biopsy Should Be Considered：
This category is reserved for findings that do not have the classic appearance
of malignancy but have a wide range of probability of malignancy that is
greater than those in Category 3. Thus, most recommendations of breast
interventional procedures will be placed within this category. By subdividing
Category 4 into 4A, 4B and 4C as suggested in the guidance chapter, it is
encouraged that relevant probabilities for malignancy be indicated within this
category so the patient and her physician can make an informed decision on
the ultimate course of action.
Category 5
Highly Suggestive of Malignancy-Appropriate Action Should Be
Taken：(Almost certainly malignant)
These lesions have a high probability (≥95%) of being cancer. This category
contains lesions for which one-stage surgical treatment could be considered
without preliminary biopsy. However, current oncologic management may
require percutaneous tissue sampling as, for example, when sentinel node
imaging is included in surgical treatment or when neoadjuvant chemotherapy
is administered at the outset.
Category 6
Known Biopsy-Proven Malignancy-Appropriate Action Should Be
Taken:
This category is reserved for lesions identified on the imaging study with
biopsy proof of malignancy prior to definitive therapy.